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MACKINNON - 2016 CRN - Brachial Plexus Reconstruction

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by

Andrew Yee

on 1 June 2016

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Transcript of MACKINNON - 2016 CRN - Brachial Plexus Reconstruction

STRETCH
TRANSECTION
AVULSION
Orientation
Exposure
Pectoralis Major
Incision of Pectoralis Major Tendon
Incision of Pectoralis Major Tendon
Tendon Sutures for Pectoralis Major
Exposure of Brachial Plexus
Repair of Pectoralis Major
Lower Plexus Injury
(-)
finger flexion, AIN, median intrinsics, ulnar ex/intrinsics, ulnar sensation
(+)
shoulder, elbow, wrist/finger extension, pronator, FCR
(-/+)
EPL
Upper Trunk
Middle Trunk
Upper Trunk
Upper Trunk
Lower Trunk
Middle Trunk
BRACHIAL PLEXUS
ROOT INJURIES
CORD INJURIES
C5,C6 INJURY
C5,C6,C7 INJURY
C8,T1 INJURY
TOTAL AVULSION
NO SHOULDER
NO ELBOW
HAND FUNCTION
ULNAR NERVE
MEDIAN NERVE
RADIAL NERVE
SHOULDER DEFICIT
Accessory
to
Suprascapular
Nerve Transfer
Medial Pectoral
to
Axillary
Nerve Transfer
Shoulder
Elbow Flexion
Shoulder
Elbow Flexion
Elbow Extension
Wrist/Finger Extension
C7,C8,T1 INJURY
DEFICITS
Finger Flexion
Median Nerve Intrinsics
Wrist / Finger Extension
Finger Flexion
Median Nerve Intrinsics
Ulnar Nerve Intrinsics
Ulnar Nerve Intrinsics
DEFICITS
DEFICITS
DEFICITS
Pronation (FCR)
LATERAL CORD INJURY
MEDIAL CORD INJURY
POSTERIOR CORD INJURY
MEDIAN
ULNAR
MEDIAN
ULNAR
RADIAL
MEDIAN
ULNAR
RADIAL
MEDIAN
ULNAR
RADIAL
COMMON PRESENTATIONS
BRACHIAL PLEXUS AVULSION
Pronation (FCR)
SHOULDER DEFICIT
ELBOW FLEXION DEFICIT
RECONSTRUCTIVE OPTIONS
Medial Triceps
/
Medial Pectoral
to
Axillary
Nerve Transfer
Double Shoulder Nerve Transfers
Accessory
to
Suprascapular
Nerve Transfer
Double Fascicular Nerve Transfers
THUMB SENSATION
FCR,FDS
/
FCU
to
Biceps
/
Brachialis
Nerve Transfers
3rd Webspace
to
Thumb Sensory
Nerve Transfer
Median Sensory
to
Distal 3rd Webspace
Nerve Transfer
END-TO-SIDE
ELBOW FLEXION DEFICIT
ELBOW EXTENSION DEFICIT
RECONSTRUCTIVE OPTIONS
Double Fascicular Nerve Transfers
FDS
/
FCU
to
Biceps
/
Brachialis
Nerve Transfers
Intercostals
to
Medial Triceps
Nerve Transfers
HAND FUNCTION
LATER
Tendon Transfers
SENSATION
DCU
to
1st/2nd Webspace
Nerve Transfer
Ulnar Sensory
to
Distal DCU
Nerve Transfer
END-TO-SIDE
Brachialis
to
Anterior Interosseous
Nerve Transfer
AIN FUNCTION
Brachioradialis
to
FDP
Tendon Weave
FDP Tenodesis
EDQ Opponensplasty
EIP Tendon Transfer for Thumb Adduction
GRIP STRENGTH
PINCH/THUMB FUNCTION
SENSATION
3rd Webspace
to
Ulnar Sensory
Nerve Transfer
PCM
to
DCU
Nerve Transfer
END-TO-SIDE
Median Sensory
to
Distal 3rd Webspace
Nerve Transfer
RECONSTRUCTIVE OPTIONS
Brachialis
to
Pronator Teres (FCR)
/
AIN
Nerve Transfer
PRONATION / AIN FUNCTION
Brachioradialis to FDP Tendon Weave
FDP Tenodesis
EDQ Opponensplasty
EIP Tendon Transfer for Thumb Adduction
GRIP STRENGTH
PINCH/THUMB FUNCTION
SENSATION
LABC
to
Ulnar Sensory
Nerve Transfer
RECONSTRUCTIVE OPTIONS
WRIST / FINGER EXTENSION
Supinator
to
Posterior Interosseous
Nerve Transfer
Horner's Syndrome
Long Thoracic Nerve
Dorsal Scapular Nerve
Phrenic Nerve
Miosis
Eyelid Drooping
Rhomboid Major/Minor
DEFICIT
DEFICIT
Serratus Anterior
Scapular Winging
FORWARD FLEXION
Diaphragm
DEFICIT
RECONSTRUCTIVE OPTIONS
0-9 MONTHS
9+ MONTHS
Nerve Transfers
Free Muscle Transfers
Trapezius Muscle Transfer
Shoulder Arthrodesis
Wrist Fusion
DONOR NERVES
Intercostals
Spinal Accessory
Contra-lateral C7
POST-INJURY
POST-INJURY
EXAMINATION
BRACHIAL PLEXUS
Lower Plexus Injury
MEDIAN
ULNAR
RADIAL
ULNAR NERVE INTRINSICS
APL
/
EIP
to
Ulnar Motor
Nerve Transfer
ULNAR NERVE INTRINSICS
APL / EIP to Ulnar Motor Nerve Transfer
CLASSIFICATION OF NERVE INJURIES
I
II
IV
III
V
VI
NERVE CONDUCTION STUDY
Favorable
Unfavorable
I, II, III
Degree of Nerve Injury
VI, V
Degree of Nerve Injury
Fibrillations + MUPs
Fibrillations + No MUPs
Recovering
Out
FAVORABLE
UNFAVORABLE
ELECTRODIAGNOSTIC STUDIES
ELECTROMYOGRAPHY
CMAP
MOTOR
SNAP
SENSORY
ECRB
to
Anterior Interosseous
Nerve Transfer
IN
OUT
OUT
OUT
RECOVERING
RECOVERING
RECOVERING
IN
IN
IN
IN
MEDIAN
ULNAR
BRACHIAL PLEXUS INJURY
HIGH OR LOW
PERIPHERAL NERVE INJURY
UNLIKELY
"DOUBLE"
RADIAL
FIBRILLATIONS
MOTOR UNIT POTENTIALS
SNAP
SENSORY
LEFT AFFECTED
RIGHT CONTROL
NORMAL
AMPLITUDES
TYPE OF ROOT INJURIES
AIN DEFICIT
INTRINSIC WASTING
THENAR DEFICIT
NO FINGER FLEXION
PRONATION DEFICIT
WRIST FLEXION/EXTENSION DEFICIT
AIN DEFICIT
INTRINSIC WASTING
FINGER EXTENSION DEFICIT
NO FINGER FLEXION
NO THENAR
EXPOSURE OF BRACHIAL PLEXUS
SUPRACLAVICULAR
INFRACLAVICULAR
SCALENECTOMY
PECTORAL TAKE-DOWN
AVULSION
Non-recordable
Reduced Amplitude
AVULSION
STRETCH
+
STRETCH
Non-recordable
Normal
Non-recordable
Non-recordable
PRE-GANGLION INJURY
POST-GANGLION INJURY
SENSORY
NORMAL
MOTOR
ABNORMAL
ABNORMAL
MOTOR
ABNORMAL
SENSORY
RADIAL
Supinator
to
Anterior Interosseous
Nerve Transfer
Brachioradialis
to
ECRB
Nerve Transfer
Wrist Flexion
PRONATION
FDS
to
Pronator Teres
Nerve Transfer
Brachial Plexus

I, Susan E. Mackinnon, am the co-inventor of the PGA Neurotube and have received research funding from AxoGen Inc.
Susan E. Mackinnon, MD
Andrew Yee, BS
Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO
I, Andrew Yee, have nothing to disclose.
Type of Brachial Plexus Injuries
Management of Brachial Plexus Injuries
Reconstruction

www.vimeo.com/user6062882

SURGICAL VIDEO LIBRARY
www.youtube.com/nervesurgery
EDUCATION WEBSITE
nervesurgery.wustl.edu
Full transcript